Widespread disease hemorrhoids
The American Society of Colon and Rectal Surgeons (ASCRS) reports that more than two-thirds of the population experience hemorrhoid symptoms at some point. In Germany, it is estimated that 3.3 million cases are treated each year. The market for medical devices for hemorrhoid surgery is growing 5.6% annually in the U.S. to a projected $1.2 billion in 2031 (TMR Inc. 2022). Approximately 2 - 3% of patients who go to the doctor with symptoms undergo surgery.
Hemorrhoids can seriously affect concentration and confidence at work, limit exercise, and make you feel insecure about your body. The good news is that we can offer a wide range of effective therapies. We can help you make a good decision about whether or not surgery is appropriate and necessary. Any surgery wants to be well thought out, because we don't have a "spare part" for the bowel outlet.
The current expert guideline presents the common treatment methods in a way that is largely understandable to laypersons and evaluated on the basis of evidence; a comparative overview of the guidelines in Europe and the USA can be found here.
And what is the optimal treatment? In addition to the stage of hemorrhoids, the most important criteria are the leading symptom (bleeding, feeling of pressure, oozing) and the extent of subjective impairment. It is also important whether and how long conservative treatment measures have helped in the past and whether there is a suspicion of a malignant change in the skin or mucosa.
Treat hemorrhoids yourself
Improve stool texture (stool consistency): The goal is to have a formed stool that is not too hard. Especially in painful conditions, patients often try to keep stool quite soft. However, stool that is too soft has a longer contact time with the skin and penetrates every tiny wound or niche in the mucosa, leading to inflammation. Soft stool is harder to control (stool smearing) and exerts less stimulus to void (with the possible consequence of voiding dysfunction). Proven measures are
How the proctologist treats
This most frequently performed treatment without surgery has the goal of tightening and stabilizing the connective tissue. In the so-called sclerotherapy (sclerotherapy), a drug is injected into the area of the vessels leading to the hemorrhoids (Blanchard's method) or, as is preferred in Europe, directly under the mucosa(Blond's method), which leads to scarring fixation and shrinkage of the hemorrhoidal nodes. This procedure can be performed painlessly on an outpatient basis and is therefore used very frequently. It usually has to be repeated several times at intervals of a few weeks. Several months may pass before the symptoms have completely disappeared.
Complications are extremely rare with the superficial injection technique of small volumes. Serious tissue damage had been reported with the phenol-oil mixtures used in the past; the sclerosing agent used today (polidocanol, ethoxysklerol®) is low-risk and usually very well tolerated. Nevertheless, sclerotherapy should be avoided in inflammatory bowel diseases and during pregnancy.
With the rubber band ligature, excess mucous membrane is tied off with a rubber ring, the tissue repels itself after one to two weeks. This reduces the size of the haemorrhoids and fixes them in their natural position by scarring. This measure must also not cause any pain, otherwise a different method of treatment must be chosen.
Like sclerotherapy, GBL can be performed on an outpatient basis in a few minutes. Local anesthesia is possible, but usually not necessary. One to two rubber bands are placed per treatment. The treatment is basically repeatable until a satisfactory result is achieved. The guideline recommends rubber band ligation as the method of choice for hemorrhoids II°.
Bleeding or post-operative bleeding are risks, especially if you are taking blood-thinning medications. The tied tissue can be uncomfortable until it is rejected, so it is advisable not to put more than one or two bands in one treatment session.
Patients with chronic inflammatory bowel diseases (Crohn's disease, ulcerative colitis) as well as with a weakened immune system or with a latex allergy should not undergo ligation treatment.
A new approach to hemorrhoid treatment is the use of medium energy laser energy, which strengthens the connective tissue and shrinks the hemorrhoids, but remains below the pain threshold. The practical implementation is comparable to sclerotherapy. We perform this treatment on an outpatient basis using a proctoscopy with a local anaesthetic gel, an anaesthetic is not required. Our experience with this technique is very good, especially persistent bleeding often responds well to this treatment.
In search of the best surgical technique
If conservative treatment of haemorrhoidal complaints does not bring sufficient therapeutic success, or if severe complaints exist from the outset, the best method for the individual case must be chosen from the available haemorrhoid surgery procedures.
The conventional methods for removing enlarged haemorrhoids, such as open haemorrhoidectomy using the Milligan-Morgan method, are tried and tested, but are associated with large wounds, thus lengthy follow-up treatment and not always optimal functional results. For stage four haemorrhoids, there is sometimes no other choice in rare cases.
By the third stage, a number of procedures have become established in which the enlarged vascular cushions are treated not by surgical ablation but by internal fixation and sclerotherapy of the haemorrhoids using laser or radiofrequency energy.
In the haemorrhoidal artery ligation according to Morinaga, the arteries supplying the haemorrhoids are cut off under ultrasound control. This suture can be continued as a spiral suture (recto-anal reconstruction), the combination of the two procedures is called HAL-RAR or Transanal Haemorrhoid Dearterialisation (THD).
Another elegant method of reducing third-degree haemorrhoids to normal size is sclerotherapy with laser (LASER haemorrhoidoplasty - LHP) or radiofrequency energy (RAFAELO method). In this procedure, the energy-applying probes are inserted into the centre of the haemorrhoid via access points of a few mm in size at the anal verge and the dilated vessels are shrunk by heat. In some centres, only local anaesthesia is even used for outpatient radiofrequency therapy.
In the Longo operation, a circular strip of mucosa is removed from the base of the haemorrhoidal ring, while at the same time connecting the edges of the cut with a ring-shaped staple suture. This both restricts the blood flow to the haemorrhoids and retracts the prolapse (hence the name stapler - haemorrhoidopexy, "fastening"). The staples heal into the scar or are gradually expelled. The procedure is widely used due to a short operation time as well as low-pain aftercare.
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Individual therapy decision
And finally, the evidence to read again
Specialists in visceral surgery, proctology
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Dr. Bernhard Hofer and Florian Liebl - Specialists in Visceral Surgery and Proctology - PartG mbB